METHODOLOGY

RESULTS

Clinical Microbiology Study Results

Thirty consecutive preoperative adult patients undergoing general plastic surgery (soft tissue only, n = 18) or maxillofacial reconstructive surgery (soft and skeletal tissue, n=12) had an anterior nasal vestibular PCR culture. In twelve of the thirty patients (40%) the PCR culture was positive for Staphylococcus aureus. Four of the patients positive for Staphylococcus aureus were also positive for MRSA. After seven consecutive days of the twice per day nasal hygiene cleaning method, eleven patients who were initially positive for Staphylococcus aureus tested negative for Staphylococcus aureus with their repeat anterior nasal vestibular swab (Table 2). The four patients who were positive for both Staphylococcus aureus and MRSA were all negative for both organisms in the repeat anterior nasal vestibular culture after the nasal hygiene method. Therefore 11 of 12 consecutive patients converted from positive to negative for Staphylococcus aureus and MRSA following the seven-day, twice per day (BID) nasal hygiene treatment. All 11 patients also successfully underwent their surgical procedures without developing a post-operative surgical site infection.

DISCUSSION

The principal organism involved in most postoperative surgical site infections, regardless of the specific procedure, is Staphylococcus aureus [8,9]. Preoperative nasal decolonization has been shown to be effective in the reduction of nasal vestibular endogenous Staphylococcus aureus, and in a corresponding reduction in the incidence of postoperative surgical site infections (SSIs) [4-8]. Current agents available for nasal decolonization were considered including mupirocin and povidone-iodine (PI). Mupirocin, a topical antibiotic, has been proven effective for topical Staphylococcus aureus nasal decolonization, however, its widespread use has led to mupirocin resistant strains of Staphylococcus aureus [6]. Povidone-iodine is bactericidal and viricidal, but professional supervision is required for use, it is not available over the counter (OTC) and can cause nasal irritation. Potential povidone-iodine allergy is also a concern. This study evaluated a new nasal decolonization methodology based on surgical prep principles which incorporates the importance of mechanical cleaning as well as the application of a disinfecting agent.

The two-step, alcohol-based method and device was selected for use in this nasal decolonization study. The antiseptic method has bactericidal activity against most gram-positive and gram-negative bacteria and is also veridical. The application method is easy to use, and follows the strict surgical principle of a two-step, dual prep technique. Particularly helpful is that it is self-administered by the patient and does not require professional supervision for use. It is a non-antibiotic method, so bacterial resistance is not an issue.

The method used for evaluating the anterior nasal swabs was PCR or polymerase chain reaction identification. This technique evaluates a vortexed buffer solution that has been soaked in a nasal swab from the nasal culture. Through vortexing and heat, Staphylococcus aureus and MRSA colonies are fragmented, and their nucleic acid identified independently. Machine sensitivity and specificity both are rated by Cepheid at 95%. The use of PCR is considered the gold standard for detection of MRSA [10].

CONCLUSION

Nasal decolonization is an evidence-based intervention that has been shown to be effective in the reduction of surgical and other healthcare associated infections. In this study a two-step, alcohol-based nasal decolonization method was administered for all patients who tested positive preoperatively for nasal vestibular Staphylococcus aureus and MRSA. Nasal decolonization twice per day for seven days pre-operatively demonstrated a 92% reduction in patients with nasal Staphylococcus aureus colonization. Eleven of twelve surgical patients were successfully decolonized using this method and underwent reconstructive surgery without development of a post-operative infection. This suggests this two-step, alcohol-based, method of decolonization should be considered as an integral part of a patient’s preoperative infection prevention protocol.

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  Table 1
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  Table 2